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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 1868 E. Hazelton, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUND STORAGE TANK RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* Facility Information Facility Waterloo Foodmart Facility 4315 E. Waterloo Rd. Stockton, CA 95215 Name: Address: Facility Ru finder Padda Contact: p Title: owner Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: 330020-464 serial #1953059 ❑ 87 piping sump Contractor Information ❑ 89 piping sump Contractor Name: Elite IV Contractor Address: 2535 Wigwam Dr. Stockton, CA CA License Number: 660076 Class: A Contractor Phone #: 209 461-6337 Insurer: State Compensation Insurance Fund p workers' Comp. #: 9084625-14 ICC Tech: Fred Babel Exp. Date: 2-20-17 ICC Installer: ❑ other: Exp. Date: ❑ Spill container replacement (not direct bury) Manufacturer Training: VEEDER ROOT Exp. Date: 10-1-2016 Indicate below type of work to be performed. Check all that apply. ® Sensor replacement Model: 330020-464 serial #1953059 ❑ 87 piping sump ❑ 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump F_ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 x other: S2 Vapor Line ❑ Leak detector replacement Model: Model: ❑ 87 -octane UST n 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ other: ❑ Spill container replacement (not direct bury) Model: Model: ❑ 87 -octane UST n 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ other: ❑ Bravo float and chain replacement Dispenser: Grade: _ Dispenser: Grade: _ Dispenser: Grade: _ Dispenser: Grade: _ `This applies only if contractor has all required certifications. ❑ Sensor replacement Model: ❑ 87 piping sump n 87 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: ❑ Leak detector replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Spill container replacement (not direct bury) Model: ❑ 87 -octane UST 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ Automatic tank gauge (ATG) replacement Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ other: PR#: PR0231760 PE: 2351I SC: 098 Accepted By/ Aris Veloso Date: Apr 2, 2015 Assigned To: p UST RETROFIT